Top 10 home health and hospice billing rejections—and how to avoid them

October 10, 2022
Categories: Home health, Hospice
Reading Time: 2 minutes

By: Jessica Rockne, director of product strategy, home & hospice, MatrixCare

A billing or claim rejection occurs when a clearinghouse or payor stops the claim from entering their processing system. The longer a rejection issue occurs without being resolved, the longer reimbursement will be delayed—potentially causing significant cash flow problems.

Here are the 10 top claim rejections in home health and hospice (and how they can be avoided):

  1. Enrollment issues (billing NPI, tax ID, etc.) Be sure that you are enrolled with the payor, confirm the billing NPI or tax ID is correct, and enroll through the specific clearinghouse to submit claims.
  2. Referral, authorization, CLIA, mammography certification Make sure your authorization is in the correct field on the claim form and that it has no characters or spaces, which are not allowed.
  3. Service line information (number of units, unit type, test results) This rejection is a specific visit information error, so it’s important to verify how your EHR is set up to pull visit information correctly to the claim.
  4. Generic rejection Review the descriptive message to help determine the actual rejection reason, as this rejection is usually paired with details.
  5. Duplicate of a previously processed claim or line This rejection means that a biller has submitted a claim which was previously submitted and is already on file with the payor. Instead of resubmitting, call the payor and verify the claim is on file. If not, verify what your clearinghouse rules are for resubmitting.
  6. Billing provider This rejection typically points back to provider demographics, such as invalid zip code. Confirming referral and authorization data can help ensure accuracy.
  7. Original reference number or payor claim control number or claim frequency If a biller is trying to submit a cancel (TOB 328), correcting the claim (TOB 327) requires the payor’s claim number from the original claim submitted.
  8. Diagnosis codes, value codes, occurrence codes, treatment codes, condition codes Diagnosis rejections are often due to using invalid or outdated diagnosis codes, commonly caused by payors not being set up correctly in the EMR. Keep in mind that episodic billing requires the county code (value code 85).
  9. Subscriber information (member ID, demographic information, patient information, release of information) This is an eligibility rejection, often due to human error with miskeyed information. Verify the patient’s eligibility and that you are submitting the claim to the correct payor ID.
  10. Procedure codes (claim or line level), procedure code qualifiers, modifiers, revenue codes, and HIPPS codes These are common rejections when the payor is not set up correctly. Be sure to refer to your contract or the payor EDI manual (usually found online). The clearinghouse will also typically provide additional information as to what is needed, missing, or incorrect.

Best practices for rejection resolution:

  • Resolve rejections within 72 hours
  • Establish a process for resolution and accountability
  • Have a goal to resolve the root cause
  • Know the payor’s reason for the rejection
  • See your EMR as the source of truth
  • Update payor information so rejections do not continue to occur
  • Work with your clearinghouse to establish additional edits
  • Strive for a rejection rate of less than 3%

Billing rejections are going to happen in home health and hospice, but they don’t need to be common. With the right technology and revenue cycle management, organizations can adopt best practices that avoid delays in cash flow.

Request a demo today to see for yourself how MatrixCare’s innovative EHR can bring efficiency to the billing process—helping to decrease rejections and create processes that help generate revenue.

Jessica Rockne
Jessica Rockne

Jessica Rockne is our Director of Product Strategy for home & hospice. She has been in the post-acute healthcare industry for over 13 years first as a Business Director of a home health and hospice organization and on the software side of the house as an Implementation Project Manager and Senior Product Manager. Jessica's experience working with hundreds of organizations all over the country gives her a unique perspective into the challenges organizations face with increased regulatory oversight, changes to the reimbursement landscape, and the impact of the public health emergency.

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